Provider Demographics
NPI:1699427971
Name:MARDER, NICHOLAS ETHAN
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ETHAN
Last Name:MARDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4203 SW HIGH MEADOWS AVE
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-3726
Mailing Address - Country:US
Mailing Address - Phone:772-222-5560
Mailing Address - Fax:844-652-8088
Practice Address - Street 1:4203 SW HIGH MEADOWS AVE
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-3726
Practice Address - Country:US
Practice Address - Phone:772-222-5560
Practice Address - Fax:844-652-8088
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-197111106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician